Labor & Delivery 2024 NUR 213 PDF

LABOR & DELIVERY Sharon Roche, MS, RNC-NIC NUR 213 ◦ Discuss theories concerning labor onset. ◦ Describe impending signs and symptoms of labor. ◦ Describe the physiological effects of labor on the mother and fetus. ◦ Distinguish true labor from false labor. ◦ Discuss characteristics of a...

LABOR & DELIVERY Sharon Roche, MS, RNC-NIC NUR 213 ◦ Discuss theories concerning labor onset. ◦ Describe impending signs and symptoms of labor. ◦ Describe the physiological effects of labor on the mother and fetus. ◦ Distinguish true labor from false labor. ◦ Discuss characteristics of a uterine contraction and how a contraction is assessed. ◦ Differentiate among the four stages of labor according to the duration and work accomplished, characteristics, contraction patterns, and maternal behaviors. ◦ Discuss effacement and dilation. ◦ Discuss the “5P’s” and their influence on labor. ◦ Define fetal lie, attitude, presentation, engagement, station, and position. ◦ Describe initial admission assessments and nursing documentation of admission. ◦ Describe evidence-based practice of continuous support for women during childbirth. ◦ Discuss assessment and documentation of FHR (fetal heart rate) during labor, including beat to beat variability, early deceleration, late deceleration, variable deceleration. ◦ Discuss the causes for changes to the fetal heart rate during labor. ◦ Describe nursing actions for a laboring woman. ◦ Describe the indications and nursing implications (side effects, assessments and patient teaching) for the following: Uterotonics, Cervical Ripening Agents, and Betamimetics ◦ Identify components in nursing strategies for improving culturally responsive care in labor and birth. ◦ Describe the unique characteristics of pain associated with childbirth. ◦ Identify non-pharmacological methods to promote comfort during labor and birth. ◦ Compare pharmacological interventions used for discomfort and pain during difficult stages of birth. ◦ Prioritize the nursing actions before and after regional and general anesthesia, (epidural block, spinal block) according to AWHONN. ◦ Discuss the nurse’s actions in ensuring maternal-fetal safety while promoting comfort during labor and birth. ◦ Discuss the following medications that may be used during Labor & Delivery: ◦ a. Sedatives ◦ b. Antiemetic: Metoclopramide (Reglan) ◦ c. H1 Receptor Antagonists: Promethazine (Phenergan); hydroxyzine (Vistaril); Diphenhydramine (Benadryl) ◦ d. Opioid Agonist-Antagonist Analgesics: Butorphanol (Stadol); Nalbuphine (Nubain) ◦ e. Opioid Antagonists: Naloxone (Narcan) ◦ f. Opioid-Agonist Analgesic: hydromorphone [Dilaudid], fentanyl [Sublimaze], sufentanyl[Sufenta] ◦ g. Narcotics: Morphine ◦ h. Inhalation gas: Nitrous Oxide (INOmax) The Five Ps of Labor ◦ Power ◦ Primary Power – involuntary uterine contractions and Ferguson reflex (reflex to push) ◦ Secondary Power – voluntary pushing ◦ Passageway ◦ Anatomy of the bony pelvis and soft tissue of the pelvic floor muscles, introitus, and vaginal canal ◦ Passenger ◦ Fetal head ◦ Fetal presentation ◦ Fetal attitude ◦ Fetal lie ◦ Fetal position ◦ Psyche ◦ Position Power ◦ Uterine contractions ◦ Primary force that moves the fetus through the maternal pelvis and out ◦ Braxton Hicks contractions ◦ Do not dilate the cervix ◦ May start from 16-20 weeks on ◦ Pre-labor “warm ups” ◦ Contraction frequency, duration and intensity increase as labor progresses ◦ Spontaneous labor - increase on their own ◦ Induced or augmented labor - induction agents (Cervidil, Cytotec and Pitocin) bring contractions into an adequate pattern and intensity to dilate cervix. Passageway ◦ Maternal pelvis and soft tissues ◦ Softening of the cartilage linking the pelvic bones due to increased relaxin levels ◦ The pelvis is broken into the top (false pelvis) and bottom (true pelvis). The true pelvis is the most important. ◦ The Inlet: Upper pelvic opening ◦ The Midpelvis: also known as the pelvic cavity ◦ The Outlet: the lower pelvic opening Passenger ◦ Fetal Head ◦ Fetal Presentation ◦ Attitude ◦ Fetal Lie ◦ Position Passenger ◦ Fetal Head – size, molding ◦ Fetal Presentation – part that enters the pelvis first (presenting part) ◦ Cephalic - head ◦ Breech - buttocks or legs enter the pelvis first ◦ 3-4% of births; more common in preterm birth, multiple gestation, anomalies of fetal head and placenta previa ◦ Complete Breech, Frank Breech or Footling Breech ◦ Shoulder - transverse lie, very rare. More common with preterm birth, high parity, placenta previa, or PPROM. ◦ Requires a cesarean section Fetal Presentation: Breech Passenger: Attitude ◦ Attitude – the position of the fetal body parts in relationship to each other. ◦ Vertex presentation – general flexion with chin to chest ◦ Sinciput presentation (also known as Military) – chin off chest, neck is straight ◦ Brow presentation – chin off chest, neck extended. Fetal brow enters true pelvis first ◦ Facial presentation – chin off chest, neck sharply extended. Face enters true pelvis first  Passenger: Fetal Lie ◦ Relation of maternal spine to fetal spine ◦ Longitudinal (vertical/vertex) ◦ Transverse (horizontal) Passenger: Position ◦ Position: relationship of the presenting part to the maternal pelvis (described with 3 letter abbreviation) ◦ First letter: L or R ◦ Second letter: O (occiput), M (mentum, which means face or brow), Sc (scapula for a transverse lie), S (sacrum for breech) ◦ Last letter: P (posterior), A (anterior), T (transverse) ◦ Can change throughout labor Fetal Positions: Occiput Fetal Positions: Transverse Psyche ◦ The woman’s psychological response to labor and birth are influenced by: ◦ Anxiety ◦ Culture ◦ Expectations ◦ Life Experiences ◦ Support Position ◦ Lithotomy vs upright? Position Improved outcomes: Decreased c/s and surgical vaginal births Reduced episiotomy and spontaneous lacerations Shorter first and second stages Increased maternal control and comfort Signs of Impending Labor ◦ Braxton Hicks ◦ Bloody show ◦ Lightening ◦ Nesting ◦ Cervical Changes ◦ GI Symptoms ◦ Weight loss Onset of labor ◦ Combination of maternal and fetal factors ◦ Newer research suggests that a cue from fetal proteins in the lungs may play a significant role in initiation of labor True vs False Labor ◦ 411 Rule Labor progression: Cervix ◦Dilation – the drawing up and opening of the cervix ◦Ranges from fully closed to 10 cm ◦Effacement – the thinning and shortening of the cervix ◦Expressed as a percentage Labor Progression: Station ◦ Describes the descent of the presenting part through the true pelvis using the ischial spines as reference ◦ Level of ischial spines is Zero and means the part is “engaged” ◦ Negative numbers mean the presenting part is still “floating” and not engaged ◦ When the presenting part moves beyond the ischial spines, it has a positive number (+1 to +3, with +3 What does this mean in L&D? ◦7/100/1 ◦3/50/-3  Cardinal Movements of Labor ◦ Engagement – head reaches ischial spines ◦ Descent – fetus moves past “0” [pt typically feels Ferguson reflex (urge to push) at +1] ◦ Flexion – fetal head moves chin to chest, cause biparietal diameter to be widest dimension of presenting part ◦ Internal Rotation – fetal head rotates to align widest part with widest part of pelvic ◦ Extension – fetal chin comes off chest and neck arches as it is born ◦ External Rotation (restitution) – fetal head, now born, rotates 4 Stages of Labor ◦ 1st Stage is broken into phases Stages and Phases of Labor Cheat Sheet ◦ First Stage: Cervical Dilation and effacement occur. Begins with onset of true contractions and ends with complete dilation (10cm) and effacement (100%) of the cervix ◦ Latent Phase: Cervix Dilation 0-3cm ◦ Active Phase: Cervix Dilation 4-7cm ◦ Transition Phase: Cervix Dilation 8-10cm ◦ Second Stage: The expulsion stage, begins with the full dilation and effacement of cervix and ends with the birth of the baby. ◦ Third Stage: Begins with the birth of the baby and ends with the expulsion of the placenta ◦ Fourth Stage: The stage of physical recovery for mother and infant. Starts with the delivery of the placenta through first 1-4 hours after birth. Stage 1 Latent Phase ◦ Historically 0-3cm (recent research suggests it can last up to 6 cm) ◦ Length varies, typically longer for nulliparous than multiparous ◦ May report cramping-like sensations similar to menstrual cramps; often able to talk through the contractions ◦ Admission to the hospital in the absence of maternal and fetal complications is not ideal in this phase. ◦ 4-1-1 (ctx every 4 mins, lasts for 1 minute, for an hour) ◦ “Six is the new Four” ◦ Delay admission until 6 cm dilated? ◦ Encourage walking, showering, light snacking and hydration Stage 1 Active Phase ◦ Dilation between 4-7 cm ◦ Fetus descends into the pelvis and internal rotation begins ◦ Multiparous woman should have cervical change of 1.5cm/hr and nulliparous woman 1.2cm/hr. ◦ Known as the Friedman’s curve and is an approximation ◦ Contractions are 3-5 minutes apart with a duration of 30-45 seconds; intensity is moderate to strong. ◦ Optimal time for an epidural block ◦ Behavior changes include: anxiousness, helplessness, intense focus throughout the contraction, unable to engage socially as she is concentrating very hard on her task at hand. ◦ Nurse has the job of helping mother remain calm and focus, using relaxation and breathing. Stage 1 Transition Phase ◦ Dilation 8-10cm, fetus is descending further into the pelvis ◦ Bloody show is often visible as the end of this stage occurs ◦ Short yet very intense phase of labor ◦ Contractions are strong, 1-2 minutes apart, lasting 40-60 seconds. ◦ Leg tremors, nausea and vomiting are common ◦ Mothers may lose control, become very irritable, uncooperative, exhausted, or dependent ◦ Contractions may elicit the urge to push or bear down from the mother at this time ◦ Encourage mother to relax and breathe forcefully outward if the cervix is not completely dilated. ◦ Pushing on a cervix will cause it to swell, not allowing it to move back Stage 2 ◦ 10 cm dilated until birth of baby ◦ Stage of the expulsion of the fetus, aka the pushing stage ◦ Duration varies, may be as little as 20 minutes or may last a few hours ◦ Duration may depend on many factors: maternal age, size of fetus, maternal pelvimetry, fetus position, maternal effort, epidural block ◦ Contractions may diminish or pause slightly ◦ May report urge to have a Bowel movement or to push ◦ May fall asleep or be oblivious to her surroundings in between pushes Stage 3 ◦ Birth of baby to expulsion of the placenta ◦ Shortest stage, average length 6 minutes ◦ If this stage lasts longer than 30 minutes the placenta is considered retained and the mother is often taken to the OR for removal ◦ When placenta is ready to come out: gush of blood appears, cord lengthens in the vagina, uterus has a spherical shape, and the uterus rises upward as the placenta descends into the vagina ◦ Fundus MUST be firm and bleeding controlled or the patient could hemorrhage  Stage 4 ◦ Stage of physical recovery for mother and infant ◦ From birth of placenta to 4 hours after birth ◦ Immediately after birth, firmly contracted uterus should be palpated at the umbilicus (@U). ◦ A full bladder or blood clot can interfere with uterine contracting leading to increased blood loss. ◦ Women may experience chills after birth most often due to the blood loss and loss of heat produced by the fetus. Warm blankets are often placed on mother for comfort. ◦ Pain from cramping in the uterus as it works to get back to the pre-pregnant state and in the perineum from a laceration or episiotomy. ◦ Tx with Ibuprofen and Ice packs Initial Admission Assessment of labor ◦ On admission: ◦ Maternal Vital signs: HR, Temp, RR, O2 Saturation, Blood Pressure, Pain scale ◦ Place mother on External Uterine Toco and External Fetal Heart Rate Monitor (FHR) ◦ Uterine toco placed at the top of the fundus and midline, firmly in place ◦ Place External FHR monitor by the fetal back using Leopold’s maneuvers Initial Admission Assessment of labor cont'd ◦ History of previous pregnancies and any issues with prior births ◦ Medical History: include STI’s and surgeries ◦ Current pregnancy history: include when care started, any issues complicating pregnancy ◦ When did labor begin? How frequent are your contractions? ◦ Did you break your water? ◦ Do you have a birth plan? ◦ Who is/are your support person/people? Hemorrhage Risk ◦ ALL women coming into labor and delivery should be assessed for Hemorrhage Risk: ◦ On admission, 30-60 minutes before birth and 30-60 minutes after birth ◦ Categories of Risk: Low Risk, Moderate Risk, High Risk ◦ Low Risk: Draw Blood and hold specimen ◦ Moderate Risk: Draw and send Type and Screen and Review Hemorrhage Protocol ◦ High Risk: Type and Cross match for 2 units PRBC’s, Review Hemorrhage Protocol, Team Prebrief  Hemorrhage Risk Assessment Low Medium High Prior cesarean birth(s) or uterine No previous uterine incision Placenta previa, low lying placenta surgery Singleton pregnancy Multiple gestation Suspected/known placenta accreta spectrum Low Medium High ≤4 previous vaginal births >4 previous vaginal births Abruption or active bleeding (> than show) Nobleeding No known previous uterine disorder Prior cesarean Chorioamnionitis birth(s) or Placenta previa, low lying Known coagulopathy incision uterine surgery placenta No history of PPH History of previous PPH History of > 1placenta Suspected pph accreta, Singleton pregnancy Multiple gestation Large uterine fibroids percreta, increta HELLP Syndrome ≤4 previous vaginal Hematocrit 4 previous vaginal births Platelets